interChange Provider Important Message
Hospital interChange Updated as of 12/09/2015
*all red text is new for 12/09/2015
Ambulatory Payment Classification (APC) Scheduled for March 1, 2016
DSS will move from the current system of hospital outpatient payment methodology based on
Revenue Center Codes (some paid based on fixed fees, some based on a ratio of costs to
charges) to a prospective payment system based on the complexity of services performed. This
change is scheduled for March 1, 2016.
Hospitals can refer to the Hospital Modernization Web page on the www.ctdssmap.com Web
site for information pertaining to the APC implementation. Please send all APC related
questions to Hewlett Packard Enterprise at the following e-mail address:
ctxixhosppay@hpe.com.
The following document was recently added to the Hospital Modernization Web page:
• APC FAQs added 10/14/2015
Outpatient Hospital APC Workshop
The topics include:
• Provider Bulletin
• Payment Methodology
• Addendum B
• Three (3) Day Rule
• Hospital Billing Changes
• Hospital Modernization Web Page
• Upcoming Changes and Training
• FAQs
Connecticut Hospital Association, 110 Barnes Road, Wallingford, CT
Friday December 11, 2015 1:00 PM – 4:00 PM
Hospital Based Practitioners Workshop
The topics include:
• Provider Bulletin
• Enrolling a Physician Group
• Re-enrollment of Hospital Based Practitioners
• Professional Billing
• Physician Fee Schedule
• Remittance Advice
• Upcoming Changes and Training
• FAQs
Internet Virtual Classroom Training
Wednesday January 6, 2016 1:00 PM – 4:00PM
Internet Virtual Classroom Training
Tuesday January 12, 2016 9:00 AM – 12:00PM
interChange Provider Important Message
To register for these workshops, visit the www.ctdssmap.com Web site and go to the Hospital
Modernization Web page and click on Outpatient Hospital APC December or Hospital Based
Practitioners Workshop under Important Messages – Connecticut Hospital Modernization. To
register, click on the registration link for either the Virtual classroom or face to face workshop
at CHA.
Provider Bulletin 2015-91 - Update to Revenue Center Codes (RCC) Requiring a Valid CPT or
HCPCS on Outpatient Claims and a Change in Prior Authorization Requirements for certain RCCs
The Department of Social Services (DSS) is adding the requirement of a valid CPT/HCPCS when
the following RCCs are billed: 273 – 274, 277, 470-472 and 479. All claim details with these
RCCs that are not billed with a valid CPT/HCPCS code will deny for Explanation of Benefit
(EOB) code 390 “Revenue Center Code Requires a HCPCS/Procedure Code.” This change is
effective for dates of service January 1, 2016 and forward on outpatient claims.
In addition, effective for dates of service January 1, 2016 and forward, hospitals will no longer
need to obtain prior authorization for RCCs 470, 471, 472 and 479.
Provider Bulletin 2015-82 - Three (3) Day Rule: Outpatient Stay Prior to Inpatient Admission
The purpose of this provider bulletin is to inform providers that the Department of Social
Services (DSS) will be implementing new Explanation of Benefit (EOB) codes in the Connecticut
Medical Assistance Program (CMAP) to enforce restrictions on outpatient claims when the date
of service is within 3 days (2 days plus the admission date) prior to an inpatient admission.
For admissions on or after November 1, 2015, all diagnostic and non-diagnostic outpatient
services, (including psychiatric diagnostic services) other than maintenance renal dialysis,
physical therapy, occupational therapy, speech therapy and audiology, provided by the hospital
or an entity wholly owned or wholly operated by the hospital 3 days (2 days plus the admission
date) prior to the inpatient claim, will post and pay with EOB code 5077 “Inpatient stay denied
due to a paid outpatient claim within 3 days prior to inpatient admission” or EOB code 5078
“Outpatient claim denied due to a paid inpatient claim within 3 days after an outpatient
claim.”
If the hospital is able to attest that the outpatient claim is unrelated to the inpatient hospital
claim and are clinically distinct and independent from the reason for admission, the hospitals
should bill with Condition Code 51 “Attestation of Unrelated Outpatient Non-diagnostic
Services” on their outpatient claim.
The post and pay status therefore enables hospitals to identify claims that will start denying
for admissions on or after March 1, 2016 if the outpatient claim is billed separately and not
billed with the inpatient stay. The informational EOB codes will post to the hospital’s
Remittance Advice (RA).
Claims Reprocessing
Hewlett Packard Enterprise previously identified an issue where outpatient claims with
Revenue Center Codes (RCCs) requiring Prior Authorization (PA) processed without a PA on file.
Hewlett Packard Enterprise resolved this issue on October 2, 2015 and claims submitted April 1,
2015 to October 5, 2015 were identified and re-processed. The RCCs that require PA will now
deny with Explanation of Benefit (EOB) code 3003 “Prior Authorization is Required for Payment
of this Service” if there wasn’t a PA on file. These claims appeared on the November 10, 2015
Remittance Advice (RA) with an Internal Control Number (ICN) beginning with region code 52.
interChange Provider Important Message
Updates to 835 Electronic Remittance Advice (ERA)
In a response to a previous request from the hospitals the following update will be made to
future 835 ERAs starting with the January 13, 2016 835 ERA.
•
EOB code 3003 utilizing CARC 204 “This service/equipment/drug is not covered under
the patient’s current benefit plan” and Remittance Advice Remark Codes (RARC) N130
“Consult plan benefit documents/guidelines for information about restrictions for this
service” will change to CARC 197 “Payment denied/reduced for absence of
precertification/authorization and will not have an RARC.”
•
EOB code 1033 utilizing CARC 16 “Claim/Services lacks information” and RARC N285
“Missing/incomplete/invalid referring provider name” will change to CARC B7 “This
provider was not certified/eligible to be paid for this procedure/service on this date of
service. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110
Service
Payment
Information
REF),
if
present”
and
RARC
N570
“Missing/incomplete/invalid credentialing data.”
Hospitals are asked to update their auto post systems accordingly.
ICD-10 Code sets
With the transition to ICD-10 code sets in the Connecticut Medical Assistance Program (CMAP),
the Department of Social Services (DSS) has implemented certain new EOB codes effective for
dates of service 10/1/2015 forward. Providers can refer to Provider Bulletin 2015-47 for a
complete list of these EOB codes. One of the EOB codes is 4039 - The primary diagnosis code is
not covered. This EOB code is currently set to a “Post and Pay” status. Providers will see EOB
code 4039 on their Remittance Advice (RA) for those claims where they use a primary diagnosis
code that has been classified as an unacceptable principal diagnosis code per coding guidelines.
Providers should utilize this “Post and Pay” period to determine the correct primary diagnosis
code for the conditions they treat. Please refer to coding resources for assistance.
The Provider Assistance Center will not be able to assist with coding questions.
Office Closure
Please be advised, the Department of Social Services (DSS) and Hewlett Packard Enterprise will
be closed on Friday, December 25, 2015 in observance of the Christmas holiday and will also be
closed on Friday, January 1, 2016 in observance of the New Year’s holiday.
Outstanding Questions
Inpatient Admissions Following Outpatient or Emergency Department Services
Inpatient claims are denying with EOB codes 0671 “DRG Covered/Non-covered Days Disagree
with the Statement Period” and 0672 “DRG Accommodation Days Inconsistent with the Header
Date Period” for inpatient admissions following outpatient or emergency department services.
Also some claims are denying with EOB code 529 “Surgical Procedure Date is Prior to Admission
Date.”
•
Claims examples and questions were sent to the Department for review. DSS stated
they are still reviewing as of 12/08/2015.
Billing for Emergency Department Professional Services Prior to an Admission
interChange Provider Important Message
In cases where the client is outpatient or emergency room prior to an admission, the hospitals
are requesting to be able to bill for professional fees separately on a CMS-1500. Effective for
admission on or after January 1, 2015, hospitals can no longer bill for their inpatient
professional fees (RCC 98X) on an inpatient claim and need to bill them on a CMS-1500.
•
Initial feedback from the DSS, based on Provider Bulletin 2014-88 “Billing for
Emergency Department Services”, these policies and procedures will not be modified
until the Department modernizes its outpatient hospital reimbursement methodology
using Ambulatory Payment Classifications pursuant to section 17b-239(d)(2) of the
Connecticut General Statutes. That change is scheduled for implementation on March
1, 2016. Question sent back to the Department for review. DSS stated they are still
reviewing as of 12/07/2015.
Medicare HMO lab crossover claims not considering the Medicare HMO co-pay.
• The Department has agreed that these claims should consider the co-pay amount and is
working on updates to the system to allow claims to be considered for payment.
Transgender gender clients and the eligibility process.
The hospital was asking who they can contact to provide updates to the client’s eligibility in
these cases and if they can bill with condition code 45 “Ambiguous Gender Category” to
override claims that deny due to gender not matching.
•
DSS states hospitals can contact the DSS benefits center, but any eligibility updates
could require the client to provide this informational change.
•
System updates will occur in the future to allow condition code 45 to override claims
and the hospital important message will be updated when the system is updated.
Billing RCC 403 - Screening Mammography.
The hospital is billing for RCC 403 twice with procedure code 77052 and G0202. RCC 403 only
allows up to the bill amount on the first line (if less than the fixed fee) and denies the second
line as a duplicate. In most cases not allowing up to the fixed fee of $117.91.
•
Hewlett Packard Enterprise requested a change to RCC 403 to allow up to the fixed fee
of $117.91 and DSS has approved to price at 1 per day. On November 12, 2015 the
system was updated to allow up to the fixed fee. Hospitals can begin to adjust their
claims to allow up to the fixed fee of $117.91 or wait for the impacted claims with
dates of service April 1, 2015 and forward to be identified and reprocessed in a future
claim cycle which is tentatively scheduled for the 1st cycle in January 2016.
Inpatient delivery stays denying due to lack of prior authorization when the delivery stays
do not require prior authorization.
Hewlett Packard Enterprise process for delivery stays is based on the primary diagnosis to
determine if the primary reason for the stay was a delivery and then overrides the
requirements for prior authorization. The hospital’s question and claim examples were
submitted to DSS on November 5, 2015 and are awaiting a reply or decision by DSS to
determine if there is an issue or if prior authorization is required based on the diagnosis billed.
DSS stated they are still reviewing this as of 12/01/2015.
interChange Provider Important Message
Primary Insurance denying claim due to not receiving information (TPL survey) from client,
then billing to Medicaid.
•
In cases where the primary insurance to Medicaid is denying the claim due to not
receiving information from the client the hospital should use the Legal Notice of
Subrogation Form (W-81) when initially pursuing commercial health insurance. This
puts the insurance company on legal notice that it must make any payment for
which it is liable for directly to the provider.
•
If the hospital does not receive payment within forty-five days, they should fully
document that every reasonable attempt was made. The provider must file a
request for assistance with the Connecticut Department of Insurance using form W82, Request for Assistance in Obtaining Payments. Department of Insurance will
furnish the hospital with a file/case number.
•
DSS is aware that other insurance carriers never cover some services. In addition,
there are some insurance companies that do not provide an actual denial
statement or, in some cases, never respond to written requests. To address these
problems and to alleviate any unnecessary burden on the provider, DSS
implemented the Third Party Billing Attempt, (W-1417). This form documents that
the hospital has made every attempt to obtain payment from the other insurance
carrier prior to claim submission to the Connecticut Medical Assistance Program.
The form may be used in place of a denial voucher for the other insurance carrier,
but may not be used in place of a Medicare denial. If the provider has not received
any insurance payment within ninety days of the date of the initial claims
submission, then the provider may bill the Connecticut Medical Assistance
Program. The Department of Insurance file number is required on the W-1417
form. Failure to include the Department of Insurance file number will result in
the claim being returned to the provider.
These instructions can be found under Provider Manual Chapter 5 “Claim Submission
Information” on the www.ctdssmap.com Web site under the hospital modernization page, by
clicking on Provider Manuals on the right side of the page. The forms can be downloaded from
the www.ctdssmap.com Web site, under Information and then Publications and scrolling down
to Third Party Liability Forms.
Third party Liability (TPL) HMS Audits
The hospitals are questioning the audit process that is taking a lot of time due to high volume
of claims selected by this audit. Most of the claims that are selected have a deductible and
the other insurance pays zero. The hospitals are questioning why they are asking for primary
voucher when the claim clearly states there is a deductible amount owed. If they don’t
provide that information in a specific amount of time the claims are voided and the money is
re-couped. DSS stated they are still reviewing as of 11/25/2015.
Billing the same RCC code on multiple details with different National Drug Codes (NDCs) but
with the same HealthCare Common Procedure Coding System (HCPCS) code.
•
If you need to bill multiple NDCs under the same RCC with the same HCPCS codes, you
will need to lump the total charges under the first NDC code and then enter zero
charge in the additional RCC line with the NDC codes. Refer to Example below.
interChange Provider Important Message
•
Please refer to provider bulletin 2008-35 “National Drug Codes (NDC) Required for
Outpatient Hospital Claims due to the Implementation of the Federal Deficit Reduction
Act (DRA) of 2005” or provider bulletin 2008-42 “Most Frequently Asked Questions
related to the billing requirements necessary to support and comply with the
implementation of the Deficit Reduction Act (DRA) of 2005” for complete instructions
on claim submission requirements for submitting National Drug Codes (NDC) required
for outpatient hospital claims.
Example
DOS
RCC
Units
NDC Code
00264196510
63323030201
Procedure
Code
J3490
J3490
Billed
Amt.
$750
$500
9/1/2015
9/1/2015
250
250
1
1
9/1/2015
9/1/2015
250
250
2
1
00264196510
63323030201
J3490
J3490
$1250
$0
Change to